Neth Heart J (2014) 22:246–248
DOI 10.1007/s12471-013-0458-z
CASE REPORT
Takotsubo cardiomyopathy complicated
by cardiac tamponade
E. ter Bals & D. A. M. Odekerken & G. A. Somsen
Published online: 7 August 2013
# The Author(s) 2013. This article is published with open access at Springerlink.com
Abstract We describe a 76-year-old patient with takotsubo
cardiomyopathy complicated by cardiac tamponade. Pericar-
dial effusion in takotsubo cardiomyopthy is common but a
cardiac tamponade is very rare. The use of anticoagulants may
increase the risk of pericardial effusion and should be consid-
ered with care.
Keywords Takotsubo cardiomyopathy . Tamponade .
Pericardial effusion . Cardioembolic complications .
Anticoagulation
Introduction
Takotsubo cardiomyopathy is a syndrome with transient sys-
tolic dysfunction of the left ventricle in the absence of signif-
icant coronary artery obstruction. The contractile function of
the mid and apical segments of the left ventricle is classically
depressed and there is hyperkinesis of the basal segments.
This leads to the typical apical ballooning of the left ventricle.
Takotsubo cardiomyopathy is much more common in women
than men and is frequently triggered by emotional or physical
stress. It has even been described after pacemaker implanta-
tion. The clinical presentation mimics acute myocardial in-
farction. Patients present most commonly with chest pain,
electrocardiographic abnormalities such as ST-segment eleva-
tion or T-wave inversion and elevated cardiac biomarkers. The
E. ter Bals (*) : G. A. Somsen
Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam,
the Netherlands
e-mail: edske.terbals@gmail.com
D. A. M. Odekerken
Spaarne Ziekenhuis, Spaarnepoort 1, 2134 TM Hoofddorp,
the Netherlands
left ventricular function usually recovers within days to
weeks. Treatment of takotsubo cardiomyopathy is supportive
to prevent heart failure. Complications include acute heart
failure, tachyarrhythmias, bradyarrhythmias, mitral regurgita-
tion, cardiogenic shock, transient left ventricular outflow tract
(LVOT) obstruction, formation of a left ventricular thrombus,
cardioembolic events, left ventricular free-wall rupture and
death [1–5].
Case
A 76-year-old female presented to the coronary care unit with
chest pain and an ECG suggestive for an inferolateral myo-
cardial infarction (Fig. 1). Her medical history consisted of
hypertension, surgery to her back and macular degeneration.
She had never smoked and had two brothers with coronary
artery disease before the age of 60. This was the first time she
had experienced chest pain. It started at the moment she was
worrying about loss of eyesight due to macular degeneration.
A coronary angiogram was performed immediately and
was normal. The left ventricular angiogram showed apical
ballooning (Fig. 2). Echocardiography showed apical dyski-
nesia and no other abnormalities. These findings confirmed
the diagnosis: takotsubo cardiomyopathy.
A beta blocker, ACE inhibitor and oral anticoagulation, to
prevent apical thrombus formation, were started. In the fol-
lowing days the patient developed atrial fibrillation and she
had recurrent chest and back pain. Analgesics were started. On
the third day her blood pressure dropped and the diuresis
decreased. Echocardiography revealed a pericardial effusion
of up to 16 mm, with diastolic collapse of the right ventricle
and >25 % transmitral flow variation with respiration which is
indicative for cardiac tamponade (Fig. 3). CT angiography
ruled out an aortic dissection. The oral anticoagulation was
Neth Heart J (2014) 22:246–248
Fig. 1 ECG at presentation
Fig. 2 Left ventricular angiogram a diastolic b systolic
247
stopped and the INR of 2.6 was antagonised with vitamin K.
Pericardiocentesis was performed. After draining 120 cc
bloody fluid, there was an immediate improvement of the
haemodynamics and diuresis.
Discussion
The exact pathogenesis of takotsubo cardiomyopathy is not
well understood. Catecholamine excess, coronary artery spasm,
microvascular dysfunction, dynamic mid-cavity or LVOT ob-
struction, inflammation and regional myocarditis may play a
role [3, 6, 7].
Inflammation extending to the pericardium may cause
pericardial effusion. An MRI study showed that pericardial
effusion is common (62 %) in takotsubo cardiomyopathy [7].
Cardiac tamponade in takotsubo cardiomyopathy, however
is very rare. In 2010, one case was described by Yeh et al. in
Circulation [8]. So far this complication has only been de-
scribed in a total number of three cases.
The use of anticoagulation may increase the risk of pericar-
dial effusion. Treatment with anticoagulants is recommended
although there are no clear guidelines whether or not to start
anticoagulation in takotsubo cardiomyopathy.
The incidence of left ventricular thrombus formation and
cardioembolic events in takotsubo cardiomyopathy is 5 % and
1.6 % respectively. Of the cardioembolic events, around 75 %
are an ischaemic brain event. Not all patients with cardio-
embolic events show a left ventricular thrombus on their first
echocardiography [9]. An ischaemic brain event may cause
irreversible damage while pericardial effusion can be drained.
248
Fig. 3 Echocardiography a parasternal long axis b transmitral flow c subcostal view
Treatment with anticoagulants should therefore be considered
at the moment of presentation to the hospital, irrespective of
the presence of a left ventricular thrombus. The use of antico-
agulants must of course be weighed against a patient’s indi-
vidual bleeding risk. Anticoagulants can be stopped after
recovery of the left ventricular function.
Conclusion
Although takotsubo cardiomyopathy complicated by cardiac
tamponade is very rare, echocardiography should be per-
formed in case of haemodynamic deterioration to exclude
pericardial effusion. The use of anticoagulation in these pa-
tients should be considered with care.
Funding None.
Conflict of interests None declared.
Open Access This article is distributed under the terms of the Creative
Commons Attribution License which permits any use, distribution, and
reproduction in any medium, provided the original author(s) and the
source are credited.
Neth Heart J (2014) 22:246–248
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